Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit

Kudzu - Fair or not

Flowering kudzu is a fast-growing legume with ...
Flowering kudzu is a fast-growing legume with a grapelike odor. (Photo credit: Wikipedia)
First published in Dermatologists Sans Borders.

New herbal fairness agents are introduced every now and then though very few actually live up to the hype. However fairness industry is huge in most parts of Asia and research on new molecules always gets much attention. Most products of plant origin are introduced by cosmetic companies, and they often rely on old patents or anecdotal evidence of efficacy. Data on their effect on the melanin synthesis pathway is either not provided or deliberately hidden.

A new study (1) (open access. Link to the full paper below) demonstrates the effect of Kudzu, a group of plants in the genus Pueraria, in the pea family. It is well known that Kudzu is rich in isoflavones. The authors, using cell biology techniques, have demonstrated that the aerial part of P. thunbergiana can inhibit tyrosinase at the transcriptional level without cytotoxicity. In addition, it can also reduce tyrosinase maturation by inhibiting a-glucosidase.

Currently, numerous compounds are used for skin whitening, such as arbutin, hydroquinone, and kojic acid. Evidence suggests that the aerial part of P. thunbergiana, considered a weed in most parts of the world where it is seen, would one day be ranked higher in the list of depigmenting herbal products.

1. Han E, Chang B, Kim D, Cho H, Kim S. Melanogenesis inhibitory effect of aerial part of Pueraria thunbergiana in vitro and in vivo. Arch Dermatol Res. 2015 Jan;307(1):57-72. Epub 2014 Jul 26. PubMed PMID: 25063049; PubMed Central PMCID: PMC4282881.

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Patient-reported outcome instruments for facial lines

The questionnaire we used to select patients.
The questionnaire we used to select patients. (Photo credit: Wikipedia)
It is often difficult to achieve an objective definition of beauty. It is even more difficult to assess the self-perception of beauty at a cognitive level. Though FDA often does not get involved much in the realm of cosmetic dermatology, Botox(R) is indeed a different matter as it is an injectable with real medical indications. Do upper facial lines (UFL) cause enough psychological morbidity to justify intervention? FDA might ask for real evidence and we better be ready.

To prove the impact of UFL treatment, first of all we need a validated tool. FDA recommends patient-reported outcome instruments or PRO as objective evidence. PRO as defined by FDA

is any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.

One of the PRO instruments available for upper facial lines is the FLO-11 questionnaire. But unfortunately FLO-11 is not validated to the FDA standards. You don’t usually find many good qualitative studies in cosmetic dermatology. But this study (1) stands apart and has been quite methodical in validating the FLO-11 questionnaire.

Yet another study in the same journal (2) presents another questionnaire called Aesthetic Dermatology and Emotional Well-being (DEBIE), designed to know the general population motivations with regard to skin appearance. Though DEBIE is quite long, the authors have done a good job in validating the questionnaire using qualitative research principles. An abridged version may be more practical.

Both these questionnaires will be useful for those planning patient satisfaction studies in cosmetic dermatology. All we need now is proof. Botulinum Toxin for UFL is fortunately our best shot at objective proof.

Read More

1. Yaworsky A, Daniels S, Tully S, Beddingfield F 3rd, Kowalski J, Fitzgerald K, Somogyi C, Burgess SM. The impact of upper facial lines and psychological impact of crow’s feet lines: content validation of the Facial Line Outcomes (FLO-11)
Questionnaire. J Cosmet Dermatol. 2014 Dec;13(4):297-306. doi: 10.1111/jocd.12117. PubMed PMID: 25399622.  ↩

2. Martínez-González MC, Martínez-González RA, Guerra-Tapia A. Aesthetic dermatology and emotional well-being questionnaire. J Cosmet Dermatol. 2014
Dec;13(4):336-45. doi: 10.1111/jocd.12109. PubMed PMID: 25399627. ↩

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Dermatoscopy and The Ethics Report 2014

A recent study 1 from India has identified dermoscopic signs of evolving lesions of vitiligo. Authors observed reduced pigmentary network, absent pigmentary network, reversed pigmentary network, perifollicular hyperpigmentation and perilesional hyperpigmentation in the evolving vitigo lesions; a white glow was present in 27 (90%) of 30 patients. It is interesting to note that reversed pigmentary network, a well-known finding in dermatoscopy of melanoma and melanocytic nevus was also noted in many cases of evolving vitiligo. The authors conclude that dermoscopy scores over routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy in doubtful cases.

Image: Reversed Pigmentary Network in evolving lesions of vitiligo. (Image Credit Dr Sarvesh Thatte)

Skin Pathergy Test (SPT) – hypersensitivity of the skin to minimal trauma – is used as a diagnostic test in Behçet’s Disease with doubtful specificity. It is usually performed over the forearm with a blunt, sterilized needle. This article 2 recommends dermatoscopy for identifying sub-clinical pathergy reaction. The clinical relevance would have been much bigger if dermoscopy could replace biopsy in identifying pathergy. The authors have not clearly established the utility of dermoscopy in SPT. Authors have also mentioned about the significance of Thrombomodulin (TM) in pathergy. Thrombomodulin (TM) is a membrane-bound receptor of thrombin on vascular endothelial cells, which activates protein C and inactivates thrombin. High blood levels of TM were strongly correlated with positive skin pathergy test (SPT), suggesting that this test could be an alternative to the SPT.

  1. Thatte Sarvesh S, Khopkar Uday S. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo. Indian journal of dermatology, venereology and leprology 2014;80(6):505-508.
  2. Scherrer Maria A, Castro Lúcia P, Rocha Vanessa B, Pacheco Leonardo. The dermatoscopy in the skin pathergy testing: case series in patients with suspected behçet’s disease. Revista brasileira de reumatologia (english edition) 2014;54(6):494-498.
Medscape published the results of a survey conducted on over 21,000 global physicians, who answered the most wrenching ethical questions in medicine. Find out the changing opinions on controversial issues. Share your views on these issues with a comment below.

[Link to the report]

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Role of Hyaluronic Acid Treatment in the Prevention Keloid Scarring

Hyaluronic acid as a volume enhancer is an important tool in any dermatologist’s armamentarium. This interesting in vitro study demonstrated that HA has the potential to normalize some of the characteristic features of keloid fibroblasts such as hyperproliferation activity, growth factor production, and extracellular matrix deposition depending on the specific genotype of the keloid fibroblast cell line. Administration of high molecular weight HA is able to reverse keloid deficiencies such as hyperproliferation and aberrant ECM deposition to a more normal phenotype. Though it is still early days as the lab results do not always translate to clinical improvement, we may soon be injecting hyalunoric acid fillers into keloids instead of steroids.

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How Chlorophyll Cuts Acne

Acne is a common teenage problem that leads to severe psychological morbidity. Isotretinoin is an effective treatment but has several serious side-effects making it a final resort in recalcitrant cases. Several anecdotal remedies exist with many websites claiming successful magic-bullets to lure gullible teenage girls to shell out their pocket money.
Image Credit Meghan @ Flikr (Image altered and text added)
Photodynamic Therapy (PDT) is another treatment modality that makes use of photosensitizers such as 5-Aminolevulinic acid (ALA) and Methyl Aminolevulinate (MAL). These chemicals get converted to porphyrin that can release reactive oxygen species on exposure to certain wavelengths of light. However, they can remain on the skin for a prolonged period leading to photosensitivity and is not suitable for dark skinned patients. The quest for a better photosensitizer has been a priority for quite some time.

A recent study published in JAAD* proposes Chlorophyll-a as the superior photosensitizer that we were waiting for. Chlorophyll-a is apparently much safer that ALA and MAL and has the following advantages:

Chlorophyll-a has intrinsic photosensitizer characteristics and does not need prior activation. Hence, the onset of action is fast.
Chlorophyll-a undergoes spontaneous permanent degradation with no risk of prolonged photosensitivity.
Chlorophyll-a is cheaper than ALA and MAL

Please share/like below to read the fourth advantage:

 The histological changes following PDT showed a sustained decrease in pilosebaceous units. Hence Chlorophyll-a PDT may be as sustainable as isotretinoin in preventing recurrence.  The combination of blue and red lights are used for activation. The study shows good promise for Chlorophyll-a PDT to emerge as a sustainable and effective treatment for recalcitrant acne.


*Byong Han Song, Dong Hun Lee, Byung Chul Kim, Sang Hyeon Ku, Eun Joo Park, In Ho Kwon, Kwang Ho Kim, Kwang Joong Kim, Photodynamic therapy using chlorophyll-a in the treatment of acne vulgaris: A randomized, single-blind, split-face study, Journal of the American Academy of Dermatology, Volume 71, Issue 4, October 2014, Pages 764-771, ISSN 0190-9622.
Keywords: acne vulgaris; chlorophyll-a; light-emitting diode; photodynamic therapy; photosensitizer; treatment

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Cosmetic Ingredients and Topical Steroid Abuse

This week I will be introducing few internet resources related to cosmetic ingredients and topical steroid abuse.

Image credit Cosmetic @ Wikipedia (Image altered and text added)

Links to all the resources are available below this post. As I have mentioned in my ten point rule, it is difficult to believe the information provided by cosmetic companies as validated research. Most cosmetic publications slump to marketing materials and most blogs in this domain are nothing but paid advertisements. Where can you find reliable scientific information on cosmetic ingredients and their potential good or bad effects?

I found John’s blog (1) on another platform while searching for skincare information. He has moved to his own blog afterwards called Triple Helixian (1). He has created evaluation rubrics for commonly used product categories such as sunscreens and cleansers and computes an ‘Alpha Score’ for products based on ingredients and packaging. This blog is an excellent resource for those looking for unbiased scientific information on cosmetic ingredients. John, if you see this, you are welcome to join our facebook group DsB and enlighten us with your knowledge through active discussions.

IADVL and many members of DsB are active proponents of the Anti-steroid abuse campaign. I am sure initiatives such as IADVL Task Force Against Topical Steroid Abuse (ITATSA) by Dr +KOUSHIK LAHIRI  would be helpful in educating patients on the perils of steroid abuse. Informed patients may be more capable of helping the campaign than journalists. Leslie is an atopic who was treated with topical and systemic steroids for symptomatic control, who later developed steroid dependence. He has started a blog called Say No To Topical Steroids (2) to raise awareness about topical steroid dependence and withdrawal symptoms. Though I doubt whether what he went through can be called a ‘steroid abuse’, It is an important eye-opener for all of us. Leslie has a huge collection of resources on topical steroid abuse. Best of luck with Leslie’s campaign though I do not endorse his tag line. I would prefer it to be ‘Say No To Topical Steroid Abuse’.

Weekly Roundup: Here is a study that demonstrates the efficacy of a vaccine suitable for use in trials against different EBV-positive cancers.(3) This study found a correlation between childhood eczema and concentrations of airborne mold in homes with water damage. (4) This may be a reason for the higher incidence of atopic dermatitis in the perpetually air-conditioned middle eastern households.

To all my friends practicing in Middle East: Do you think atopic dermatitis is more common there?

Please support/like below to see the references to the blogs and articles.

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Time to respect your patient privacy

In a small town called payyanur in Kerala, INDIA, three doctors were suspended for allegedly sharing a labour room video of triplets being delivered by C-section on social media. The powerful local media rebuked the medical community for their irresponsible behaviour.

Is taking clinical photos on your mobile second nature for you?   Do you share them on Facebook? 

Photo credit: Jay Wennington @
Think again. In this fast growing digital world, it is time to consider the repercussions. This is not a review of the privacy concerns. Please refer to Kunde (below) for a short and sweet review on ethical and medico-legal considerations of digital photography in dermatology. This is about a solution, though little cumbersome and incomplete.

Dermatology is a speciality that depends on visual cues. Photography can even be considered therapeutic in dermatology, since it is an important part of disease monitoring. Social media like facebook is an important and popular platform for crowdsourcing diagnosis. This is especially important for those practicing in resource deprived areas. How can this be achieved without compromising patient privacy?

I have developed a tool for visual diagnostic information encoding. The tool called LesionMapper(TM) captures information such as location, distribution, progression and severity using pre-defined representative lesion images and icons. It also provides the capability to create lesion icons from existing clinical images. Without further ado here is the link to LesionMapper(TM):

Lesion Canvas for LesionMapper(TM)

The instructions tab has details on how to use it. Below I have added basic steps to add a lesion from your photograph. Please note that using LesionMapper(TM) does not guarantee anonymity. It is your responsibility to ensure that you have obtained the necessary consent. If the preset images and icons are insufficient, you can crop the lesion from the clinical image  itself as below.

  1. Go to
  2. Click on Upload Image 1 (Blue Button)
  3. Upload your image. Select only the lesion and follow instructions. (In the new window)
  4. Click on Upload 1 (White button). Image will be added to canvas. If not press the button again.
  5. Drag the image to the area of involvement. You can resize the image if needed.
  6. Click on the Download button (A small button right below the image). You can also save it on the site. You will be provided with an ID that can be used to render the image by clicking on Load.
Please share below to see the reference to medico-legal considerations in dermatology photography.

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About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.


Bell Raj Eapen
Hamilton, ON

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